Failure to Provide Timely Fire Response and Resident Assessment During Fire Incident
Penalty
Summary
Facility staff failed to provide appropriate treatment and care according to physician orders, resident preferences, and goals, as evidenced by a fire incident involving a resident who was engulfed in flames. Staff did not immediately extinguish the fire using a fire extinguisher and instead used a non-fire retardant blanket, which worsened the fire. After the fire was extinguished, staff did not assess or render aid to the resident, who subsequently expired in the facility. The resident had a history of stroke with left-sided weakness, was dependent on staff for mobility and transfers, and was a known smoker with a care plan addressing smoking-related risks. The last clinical assessment for this resident was completed prior to the incident, and no assessment was documented after the fire. During the fire, staff failed to follow the facility's fire safety plan for evacuating residents from the affected hall. Multiple residents were left in their rooms during the fire, resulting in prolonged exposure to smoke. Security footage and fire department reports confirmed that staff response was delayed and uncoordinated, with some residents being evacuated only after several minutes had passed. The fire department found that some residents were sheltered in place due to smoke conditions, and the fire was confined to the bed of the resident who expired. The fire alarm system operated as intended, alerting staff and prompting a response, but the evacuation process was not executed according to established protocols. Interviews with the facility's Medical Director and DON revealed that staff were not trained on how to respond to residents with severe burns prior to the incident. The DON acknowledged that no assessment was performed on the resident after the fire, which was a deviation from professional standards of practice. The Medical Examiner reported that the deceased resident suffered from second and third-degree burns, with significant charring and soot deposition in the airway, indicating the resident was breathing during the fire. The report also documented deficiencies in care and services for multiple other residents on the affected hall, including failures to provide assistance with mobility and ADLs as outlined in their care plans.